Free Medicaid Overpayment Notice, HCF 10093 - Wisconsin


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State: Wisconsin
Category: Health Care
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http://dhs.wisconsin.gov/forms/F1/F10093.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10093 (07/08)

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MEDICAID / BADGERCARE OVERPAYMENT NOTICE INSTRUCTIONS: To be completed by an Income Maintenance worker at the county agency or Income Maintenance Program Integrity staff and mailed to recipient. Personally identifiable information is used only for the direct administration of the Medicaid / BadgerCare program. Recipient Name (Last, First, MI) Recipient Address (Street, City, State, Zip Code)

Overpayments occur when Medicaid / BadgerCare benefits are paid for someone who was not eligible for them, or when Medicaid / BadgerCare payments are made in an incorrect amount. The amount of recovery may not exceed the amount of the Medicaid/BadgerCare benefits incorrectly provided. You received more Medicaid / BadgerCare benefits than you were eligible for. The amount of your overpayment is $ from (date) to (date).

By law you must repay the overpayment resulting from the type of error checked below. A Medicaid / BadgerCare Repayment Agreement will be sent to you that will explain how you can repay this overpayment. Reason for Overpayment Recipient Error Recipient error is when a recipient, or any other person responsible for giving information on the recipient's behalf, unintentionally misstated the facts. Recipient error includes: Misstatement or omission of facts by a recipient, or any other person responsible for giving information on the recipient's behalf, at a Medicaid / BadgerCare application or review. Failure on the part of the recipient, or any person responsible for giving information on the recipient's behalf, to report changes within 10 days.

Fraud Fraud occurs when a recipient intentionally omits or provides erroneous information at the time of application or review.

MEDICAID / BADGERCARE OVERPAYMENT NOTICE F-10093 (07/08)

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Explanation of Error:

Right to a Hearing You have the right to request a fair hearing if you believe the agency's decision that you received a Medicaid / BadgerCare overpayment is wrong or if you disagree with the amount of the overpayment. You will receive a Notice of Decision that explains your hearing rights and how to appeal. The notice will explain that you may request a hearing orally or in writing, within 45 days of the date of notice. You may be represented at a hearing by anyone you choose. SIGNATURE Income Maintenance Worker or Program Integrity Analyst Date Signed Agency Case Number

Retain a copy for the case file. Wisconsin Statutes 49.46

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